European Journal of Case Reports in Internal Medicine <p><strong>The&nbsp;<span class="HPblu">European Journal of Case Reports in Internal Medicine</span>&nbsp;</strong>is an official journal of the European Federation of Internal Medicine (EFIM), representing 35 national societies from&nbsp;<a href="">33 European countries</a>.&nbsp;<br><br>The journal’s mission is to promote the best medical practice and innovation in the field of acute and general medicine. It also provides a forum for internal medicine doctors where they can share new approaches with the aim of improving diagnostic and clinical skills in this field.&nbsp;<strong><br><span class="HPblu">EJCRIM&nbsp;</span></strong>welcomes high-quality case reports describing unusual or complex cases that an internist may encounter in everyday practice. The cases should either demonstrate the appropriateness of a diagnostic/therapeutic approach, describe a new procedure or maneuver, or show unusual manifestations of a disease or unexpected reactions. The Journal only accepts and publishes those case reports whose learning points provide new insight, contribute to advancing medical knowledge both in terms of diagnostics and therapeutic approaches. Case reports of medical errors, therefore, are also welcome as long as they provide innovative measures on how to prevent them in the current practice (Instructive Errors).&nbsp;<strong><br></strong>The Journal may also consider brief and reasoned reports on issues relevant to the practice of Internal Medicine, as well as Abstracts submitted to the scientific meetings of acknowledged medical societies.<br><br> <strong>EJCRIM</strong> is peer-reviewed with single-blind review and freely accessible to all.</p> SMC media s.r.l. - Via Giovenale 7, Milan - Italy en-US European Journal of Case Reports in Internal Medicine 2284-2594 <h3>Copyright and Disclosures</h3> <p>Every author must sign a copyright transfer agreement and disclose any financial or professional interest in any company, product, or service mentioned in an article. This authorization includes all submitted text including illustrations, tables, and other related materials.<br> If this submission contains any <strong>material that has been previously published</strong>, this authorization <strong>must also be accompanied</strong> by all necessary Permission to Reproduce Published Material" forms completed by the current copyright owner. If this submission contains any <strong>previously unpublished material</strong> for which the person(s) signing this form <strong>does not own copyright</strong>, an additional "Authorization to Publish" form is required from each corresponding copyright owner.</p> <h3>Copyright Transfer Declaration</h3> <p>(this may be included as a word document with your manuscript submission)<br> I confirm that I am the current copyright owner of the material described above and hereby transfer and assign to the European Journal of Case Reports in Internal Medicine (EJCRIM) all copyrights in and to the material for publication throughout the world, in all forms and media, in English and in any other language(s). Such transfer includes publication in this and all future editions of the publication named above and in any other publications (including slide collections and any other nonprint media) of EJCRIM and gives EJCRIM the sole authority to grant rights for use of the material by others.<br> I waive EJCRIM from any liabilities connected to the incorrect copyright statement.<br>The copyright agreement form can be downloaded <a style="font-weight: bold;" href="/documents/EJCRIM_Copyright_auth.pdf">HERE</a> or requested to the editorial office <a style="font-weight: bold;" href=""></a></p> Pancreatitis Can Present Like Cancer: Lymphoplasmacytic Sclerosing Pancreatitis in a Patient with a History of Gastric Carcinoma <p>Autoimmune pancreatitis has been associated with many syndromes in the presence of increased immunoglobulin levels. IgG4 antibodies are elevated in the context of lymphoplasmacytic sclerosing pancreatitis associated with IgG4-related disease. We present the case of a 74-year-old man diagnosed with autoimmune pancreatitis on a cancer background. Awareness of this condition in the cancer patient is crucial for timely diagnosis. Infectious complications might have implications for the choice of immunosuppressant.</p> Susana Rocha Amaral Luís Elvas Tatiana Pereira Gabriela Sousa Paula Jacinto ##submission.copyrightStatement## 2019-08-06 2019-08-06 10.12890/2019_001205 Acute Longus Colli Calcific Tendinitis: A Rare Cause of Neck Pain <p>A 48-year-old man presented to our emergency department with neck pain without sensorimotor deficit and with a sore throat without signs of infection. Magnetic resonance imaging was performed because the patient had not responded to regular treatment and a blood test had showed inflammation. The images revealed cervical prevertebral fluid collection and calcification, compatible with acute calcific tendinitis of the longus colli muscle. Prednisolone 50 mg with pantoprazol 40 mg was administered for 5 days with rapid resolution of symptoms. Acute calcific tendinitis of the longus colli muscle is a rare and possibly underdiagnosed cause of atypical neck pain and sore throat.</p> Nicolas Frei Nicolas Bless ##submission.copyrightStatement## 2019-08-02 2019-08-02 10.12890/2019_001126 A Case of Spontaneous Regression of Pulmonary Small Cell Carcinoma <p>An 82-year-old man was examined using chest computed tomography after treatment for pneumonia. Imaging showed a nodular shadow in the left lower lobe with associated enlarged lymph nodes. A polypoid tumour was observed on bronchoscopic examination, and the histological findings showed pulmonary small cell carcinoma with infiltration of CD3-positive and CD8-positive lymphocytes. The patient declined any antitumoural therapy and experienced an exacerbation of heart failure treated with atrial natriuretic peptide. Eighteen months after the diagnosis, the polypoid tumour had disappeared. T lymphocyte-mediated immunity and the antitumoural effects of atrial natriuretic peptide may have influenced the observed spontaneous regression.</p> Motoi Ugajin Hisanori Kani ##submission.copyrightStatement## 2019-07-31 2019-07-31 10.12890/2019_001203 Detecting Pneumoperitoneum via Point-of-Care Abdominal Ultrasound: To See Beyond Touch <p>Point-of-care ultrasound is increasingly important in the management of acute medical emergencies. An elderly man was brought to the emergency department after 2 days of fever and urinary retention. He was drowsy and had peri-arrest arrhythmia. He was hypoperfused peripherally with a systolic blood pressure of 45 mmHg and so was managed as for septic shock with no obvious aetiology. Chest and abdominal physical examinations were unremarkable. The source of sepsis was unclear. A point-of-care abdominal ultrasound was performed by the reviewing internist which detected a pneumoperitoneum, leading to a change in diagnosis to a perforated viscus which was confirmed later by a CT of the abdomen and pelvis.</p> Peh Wee Ming Lok Teng Joo ##submission.copyrightStatement## 2019-07-29 2019-07-29 10.12890/2019_001193 T-Cell/Histiocyte-Rich Large B-Cell Lymphoma: A Challenging Diagnosis <p>Epstein-Barr virus (EBV) is a double-stranded virus that shows tropism for B-cell lymphocytes. EBV-infected patients usually present with tonsillitis/pharyngitis, cervical lymphadenopathy and fever, but an atypical presentation can mimic lymphoproliferative disease. <br> We present the case of a 77-year-old woman with asthenia, fever, oral ulcers and peripheral lymphadenopathy. After extensive evaluation, including anatomopathological and immunocytochemical examination of excisional lymph node biopsy samples, it was still not clear whether the patient had EBV infection or diffuse large B-cell lymphoma.<br> In this case report, the authors describe how it can be difficult to differentiate between two different, although related, entities, making diagnosis of lymphoma highly challenging.</p> Sara Barbosa Pinto Leonor Naia Gisela Ferreira Margarida Eulálio ##submission.copyrightStatement## 2019-07-26 2019-07-26 10.12890/2019_001077 Hiccups and Inappropriate ADH Secretion Syndrome as Presentations of Tick-Borne Disease <p>Tick-borne diseases (Lyme disease and tick-borne encephalitis) are becoming a major public health concern. Rapid and correct diagnosis is crucial for complicated cases but is often delayed because of low suspicion or unusual clinical presentation. In this paper the authors describe two atypical presentations of Lyme disease and tick-borne encephalitis in order to help clinicians resolve diagnostic challenges.</p> Andrea Da Porto Michele Battellino Gianluca Colussi Vito Di Piazza Leonardo Sechi ##submission.copyrightStatement## 2019-07-24 2019-07-24 10.12890/2019_001188 A Case of Binocular Vertical Diplopia after Intratympanic Gentamicin Therapy <p>Intratympanic gentamicin therapy is a useful alternative treatment for refractory Meniere's disease and is generally well tolerated. Visual disturbances as side effects of this treatment are rarely reported in the literature. In this report we describe the case of a 52-year-old woman with refractory Meniere's disease who developed binocular vertical diplopia following intratympanic gentamicin therapy. Spontaneous resolution of diplopia occurred within 2 weeks. The development of diplopia should be discussed as a potential complication with patients undergoing intratympanic gentamicin therapy.</p> Giacomo Cioffi Francesca Irene Rampolli Emmanuela Pareti Nicola Melik Francesco De Righetti ##submission.copyrightStatement## 2019-07-22 2019-07-22 10.12890/2019_001187 Adding Herbal Products to Direct-Acting Oral Anticoagulants Can Be Fatal <p>Direct-acting oral anticoagulants (DOACs) are used to prevent and treat systemic and cerebral embolisms in patients with non-valvular atrial fibrillation (NV-AF). The use of DOACs with herbal products without consulting healthcare professionals increases the possibility of drug–herb interactions and their adverse effects. An 80-year-old man on dabigatran with a known history of NV-AF presented with a 1-day history of haematemesis and black stool which began 3 days after he had started taking a boiled mixture of ginger and cinnamon. The patient was hypotensive and treated as a case of gastrointestinal bleeding and haemorrhagic shock. Despite continuous aggressive resuscitation measures including administration of a reversal agent for dabigatran, we were unable to control bleeding and the patient died within 24 hours. The interaction of ginger and cinnamon with dabigatran led to fatal bleeding.</p> Ossama Maadarani Zouhair Bitar Mohammad Mohsen ##submission.copyrightStatement## 2019-07-19 2019-07-19 10.12890/2019_001190 Unusual Pneumonia Mimic <p>Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. Such conditions may even be emergencies, like appendicitis. Subhepatic appendix is a very rare entity which may be caused by caecum dehiscence failure. The authors present the case of a 55-year-old immunocompetent man admitted to the Emergency Department with sepsis and severe hypoxaemia. Chest x-ray showed right lower lobe infiltrate, and community-acquired pneumonia was diagnosed. The patient was started on broad-spectrum antibiotics, but he continued to deteriorate and after 3 days developed abdominal complaints. Exploratory laparoscopy revealed an abscess caused by perforated subhepatic appendicitis. <br> Subhepatic appendicitis presents a diagnostic challenge and its clinical presentation may mimic that of other entities. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial.</p> Joana Ricardo Pires Maria José Moreira Margarida Martins Clarinda Neves ##submission.copyrightStatement## 2019-07-17 2019-07-17 10.12890/2019_001181 Alteplase for Massive Pulmonary Embolism after Complicated Pericardiocentesis <p><em>Background:</em> The occurrence of a high-risk pulmonary embolism (PE) within 48 hours of a complicated pericardiocentesis to remove a haemorrhagic pericardial effusion, is an uncommon clinical challenge. <br> <em>Case summary:</em> The authors report the case of a 75-year-old woman who presented with signs of imminent cardiac tamponade due to recurring idiopathic pericardial effusion. The patient underwent pericardiocentesis that was complicated by the loss of 1.5 litres of blood. Within 48 hours, the patient had collapsed with clear signs of obstructive shock. This was a life-threating situation so alteplase was administered after cardiac tamponade and hypertensive pneumothorax had been excluded. CT chest angiography later confirmed bilateral PE. The patient achieved haemodynamic stability less than an hour after receiving the alteplase. However, due to the high risk of bleeding, the medical team suspended the thrombolysis protocol and switched to unfractionated heparin within the hour. The cause of the PE was not identified despite extensive study, but after 1 year of follow-up the patient remained asymptomatic. <br> <em>Discussion:</em> Despite the presence of a contraindication, the use of thrombolytic therapy in obstructive shock after exclusion of hypertensive pneumothorax can be life-saving, and low-dose thrombolytic therapy may be a valid option in such cases.</p> Ricardo Cleto Marinho José Luis Martins Susana Costa Rui Baptista Lino Gonçalves Fátima Franco ##submission.copyrightStatement## 2019-07-15 2019-07-15 10.12890/2019_001150